Inspection on 30/07/07 for Mundy House Care Centre

This inspection was carried out on 30th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mundy House Care Centre 03/03/10

Mundy House Care Centre 06/04/09

Mundy House Care Centre 24/06/08

Mundy House Care Centre 06/01/07

Mundy House Care Centre 28/06/06

Mundy House Care Centre 02/02/06

Mundy House Care Centre 16/06/05

Mundy House Care Centre 05/03/05

Mundy House Care Centre 15/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mundy House Care Centre Church Road Basildon Essex SS14 2EY Lead Inspector Carolyn Delaney Unannounced Inspection 30th July 2007 07:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mundy House Care Centre Address Church Road Basildon Essex SS14 2EY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01268 520607 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Manager post vacant Care Home 65 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (65) of places Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Personal care to be provided for older people aged over 65 years. Personal care can be provided for up to a maximum of three service users with dementia. The total number of service users for whom personal care can be provided shall not exceed 65. 6th & 22nd January 2007. Date of last inspection Brief Description of the Service: Mundy House Care Centre is a large home that was purpose built in 1965. Care and accommodation is offered for up to sixty-five older people, including up to a maximum of three service users who have a diagnosis of dementia. It is close to local shops and is on a bus route with services to Basildon and Wickford. The majority of bedrooms are situated on both floors of the main building. An additional eight bedrooms are sited in the Lodge annexe, which can be reached through an internal walkway on the first floor. Single and double bedrooms are available and the majority offer ensuite facilities. Access to all rooms is available via passenger lift. The home has a number of communal lounge/dining areas. There is a courtyard and garden area accessible to service users. The range of fees for accommodation is £426.09 - £ 500.00 per week. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced Key inspection carried out on 30th July 2007. It took place over ten and a half hours between 07.30am and 6.00 pm. I was accompanied by inspector Michelle Love. As part of the inspection process the relatives of eighteen residents living at the home, the residents general practitioner and other health professionals who are involved in the care for residents were contacted by post and given the opportunity to make comment about the home by completing a ‘Have your say about’ survey. At the time of writing this report seven of those people contacted had responded. Records including assessments, care plans, daily care notes, and medication records and risk assessment documents in respect of a number of people living at the home were examined. The homes manager, and five members of staff were spoken with and a number of records including duty rotas and staff recruitment files were examined. Six residents and a number of visiting relatives were spoken with. A tour of the premises was carried out. Key standards as identified in the intended outcomes sections of this report are inspected at each key inspection. Key standards are identified for each section of the report. Where other standards have not been assessed these will have been assessed at previous inspections. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk. The judgements made in this report are based upon the information collected during the site visit, the information provided by residents relatives and other relevant individuals, and other information received by the Commission from the home and other parties. Below is a brief summary of the findings of the inspection. More detail is contained within the main body of the report. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There have been a number of improvements made since the last inspection. In particular the way in which staff working at the home record information about residents needs and how they provide care and support to residents. There have been improvements in the range of activities provided by the home and there was a welcoming and homely feel about the home. There has been a reduction in the number of complaints received about the home and there are more opportunities for residents and their relatives to comment about the home and to make suggestions for improvement. The homes manager has carried out an Annual Quality Assurance Assessment for the home, which identifies what aspects of care and service, the home does well, areas for improvement and how these are to be achieved in the future. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are only offered a place at the home once their needs have been assessed by a senior member of staff working at the home and a decision has been made that the home will be able to meet the person’s needs. EVIDENCE: Before a person is offered a place at the home, a senior member of staff visit them in their home / or in hospital to carry out an assessment of the persons care needs and to identify any specific risks to the individual such as the risk of developing pressure sores due to poor mobility, weight loss due to poor dietary intake or the risk of sustaining injury through falls. The pre- admission assessments for two people who have moved into the home since the last inspection were examined. Some sections of the home assessment document were not completed by staff however there was Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 10 sufficient information recorded so as to make the decision that the home could meet the needs of the individual. In addition to the assessment carried out by staff working at the home both people had been assessed by a social worker and a copy of the assessment document was available to staff prior to the person moving into the home. It is the policy of the organisation that a draft pre-admission care plan is completed for each person before they move into the home so that staff will have information about residents needs in preparation for their admission. These documents had been completed for residents whose documents were sampled and examined. Mundy House provides intermediate care for up to nine who may need extra support to enable them to move home or who are awaiting a permanent place in a care home. At the time of this inspection the home was providing intermediate care for one person. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care for people living at the home is planned and reviewed so as to ensure that staff have the necessary information to enable them to deliver proper care and support. Risks to the health and safety of residents are well managed. The arrangements and staff practices in respect of the safe handling & administration of medicines require immediate review and action. EVIDENCE: Five of the seven people who completed ‘Have your say about’ surveys said that they feel that the home always meets their relative’s needs. The remaining two said that the home usually does. Each of the seven said that they are kept up to date with important issues affecting residents in the home and the majority said that they were provided with enough information so as to be able to make decisions. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 12 The care plans for eight people living in the home were assessed. There has been improvements in the way in which staff record information about each person and what care and support staff are to provide so as to assist residents live their lives as independently as possible. It was positive to note that for the majority of care plans which were assessed (generally those which have been written since the last inspection) that where these care plans are reviewed by staff each month that staff make specific reference to whether there have been any changes to the persons needs or condition since the last review date. For example where it had been identified that a person was at risk of fall and a care plan had been developed, when staff reviewed the plan they indicated whether the person had fallen since the last review so as to determine if the plan was effective or if amendments were needed. The care plan for the person who had been admitted to the home for intermediate care did not include detailed information about this persons needs and how these were to be met. For example where needs had been identified in respect of assisting the person with washing and dressing and moving about the home there was no plan of care in place as to how staff working at the home were to support and assist the resident. There have been improvements in the way in which risks to residents are assessed and managed. Assessments are carried out for residents where they have been identified at being of risk of weight loss, developing pressure sores and risks of injury from falls or the use of bedrails. It was positive to note that staff reviewed these risk assessments regularly and that appropriate action had been taken for example where people with poor or reduced appetite had lost weight. The way in which staff working at the home store, handle and administer medicines was assessed. Records indicate that 100 of staff who are responsible for handling and administering medicines in the home had received training. On the day of the inspection the temperature of the room where medicines are stored was 30 degrees Celsius. Other records indicated that the medicines in the home are regularly stored at temperatures in excess of the recommended temperature of 25 degrees Celsius. One bottle of medicine was out of date. Staff working at the home who are administering medicines wear a red tabard and the policy is that these staff are so far as it is possible not to be disturbed while they are administering medicines. However on the morning of the inspection the senior member of staff who was administering medicines was observed to leave the room to assist other members of staff to move and transfer residents from the dining room to the lounge. On one such occasion the member of staff left a residents medicine on the top of the trolley. This practice is not in line with the homes policies and procedures and could put residents at risk. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 13 On assessing a sample of residents Medication Administration Records (MAR) it was noted that during the past month six people living in the home had on a number of occasions not received the medicines, which had been prescribed for them as these medicines were ‘out of stock’. For example two people living at the home had not received on a number of occasions the medicine prescribed to manage the effects of Parkinson’s disease, two people had not received their eye drops and two people had not received the analgesia which had been prescribed for pain relief. There was no evidence that staff working at the home had taken all steps so as to ensure that there were sufficient medicines available in the home for residents living there or that they had made residents G.P’s aware that residents had not received medicines. Following this inspection a Serious Concerns letter was issued in respect of the issues identified in respect of the safe handling and administration of medicines in the home. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvements in the way in which staff support residents in their daily lives. More could be done so as to provide a good quality of life for residents who have difficulties in communicating verbally with staff. Meals are served in a congenial setting and staff generally support residents according to their needs EVIDENCE: There have been improvements in the provision of activities in the home since the last inspection. A new activities coordinator has been employed to work at the home and this person was spoke with during the inspection. This person provided evidence of the planned activities and fundraising events for the coming months. Activities include bread making, crafts, music and quizzes. A residents meeting had been recently held and a number of people commented that there was not enough to do during the day. The homes manager undertook to make improvements to the range of activities made available and the homes activities coordinator was in the process of discussing individual residents preferences for activities so as to provide a better range of Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 15 opportunities for residents. Following on from these discussions the activities coordinator had started a knitting group for some of the female residents in the home. During the day of the inspection some of the more able residents were observed to enjoy activities such as bread making, sing-along and nail care and some members of staff were observed to interact and engage in a positive way when supporting residents. All of the people who completed surveys said that they were enabled to keep in touch with their relatives who live in the home. As part of the inspection a period of two hours was spent observing a group of three residents who were unable to communicate their needs verbally to staff. The inspector observed these residents using a Short Observation For Inspection tool. This assessment has been specifically designed to assess people who have dementia. The tool assesses the person’s mood over periods of five minutes and how interaction of staff or others affects the person’s mood and general state of being. During the assessment, which took place between 11am and 1pm it, was noted that the only contact staff had with the three residents was when they provided midmorning tea. For the rest of the time staff entered the lounge room and passed by residents without any engagement or interaction with residents. During this time two staff were observed to provide activities for other residents in the lounge area. During this two-hour period it was noted that there were periods where residents were alert and there were opportunities for these residents to be stimulated and occupied if staff had been available to offer support and to engage with the resident. The findings of this observation were discussed with the homes manager. More could be done so as to improve the activities provided by the home. The activities coordinator said that there is a budget of £130 per month for activities. There are problems accessing activities outside of the home as the homes minibus is shared with the day care unit and the only person who can drive the minibus is the homes manager. There have been improvements in the way in which people in the home are supported at mealtime. Since the last inspection one of the communal areas had been re-arranged so as to provide a large dining room. Both inspectors observed the serving of breakfast and the lunchtime meals. At breakfast staff were observed to offer extra tea, toast and cereal to residents. Staff chatted and interacted in a positive way with residents. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 16 The same was observed during the serving of the lunchtime meal, however some staff when feeing residents were doing so too quickly for residents without taking the time to ensure that the resident was ready for the next portion of food. At a recent resident meeting some residents said that sometimes the food is not very hot. The acting manager said that some temperature-controlled trolleys would be purchased so as to keep food hot until it is served. Residents who were spoken with during the day of the inspection said that they enjoyed the food in the home. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally people feel that their complaints and concerns will be dealt with and responded to appropriately. The home has improved its measures for safeguarding vulnerable people from abuse, harm or neglect. EVIDENCE: The home has a policy and procedure and procedure for receiving and dealing with complaints which includes recording the findings of any investigation carried out and the outcome of the investigation. Each of the seven people who completed ‘Have your say about’ surveys said that they knew who to speak with if the were unhappy or needed to make a complaint. Of these seven people four said that if they raised any concerns or made complaints that these were always dealt with and responded to appropriately and the remaining three people said that they usually were. The records which were available in respect of how complaints are received, investigated and responded to were not maintained in accordance with the homes policy and it was not clear from records what action had been taken in respect of the two complaints for which there were records available. At the time of this inspection a member of the organisations quality assurance team was dealing with the most recent complaint and informed inspectors that a Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 18 meeting had taken place with social services in respect of this. However there were no records available in respect of this meeting or any other investigation into the complaint. There has been one complaint since the last inspection, which was referred to the Essex Safeguarding Team for investigation and the resident was moved from the home. From the information provided by the homes manager during the inspector it was noted that 80 of staff working at the home had received training in respect of safeguarding people who may be vulnerable, from abuse, harm and neglect. A number of residents and their relatives who visited the home during the day of the inspection commented that residents were ‘treated well’ and ‘were well cared for’. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvements to the layout of the home since the last inspection. EVIDENCE: The homes manager has arranged for one of the communal lounge areas to be used as large dining room. This has meant that residents can be better supported at mealtimes. All communal areas were noted to be clean and free from odours during the inspection. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are not always employed in sufficient numbers for the needs of residents living in the home. The procedures for recruiting staff to work at the home are not consistently robust and some staff working at the home have not received training for the work they are to perform and the needs of residents. EVIDENCE: From the information provided by the homes manager on the day of the inspection it is noted that the home employs a total of 33 care staff including 10 senior care staff, 6 kitchen staff, 7 laundry staff, 2 activities coordinators, an administrative person and a maintenance person. The homes manager said that there should be ten staff on duty during the day and four at night. The duty rotas for the period between 9th & 30th July 2007 were examined and there were a number of occasions where these staffing levels were not maintained and on occasions there were seven staff on duty during the day and three at night. While it is noted that there are vacant beds in the home it was not clear that the reduction in staffing numbers had been carried out having taken into account the needs and dependencies of people living in the home. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 21 During the inspection staff were observed for the most part to act and treat residents in a caring way and both residents and visitors who were spoken with during the inspection commented that staff working in the home were ‘good’. Four of the seven people who completed ‘Have your say about’ surveys said that their relatives are always supported as agreed or expected. The remaining three said that residents usually were. The staff recruitment files for each of the thirteen people who have been employed to work at the home since the last key inspection were examined. Candidate’s employment histories were not checked consistently, references were not obtained from each person’s previous employers and staff did not always undertake a period of induction. There was evidence that all staff had a PoVA First check or Criminal Records Bureau (CRB) disclosure obtained prior to them being employed at the home. From the staff training statistics provided by the homes manager it was noted that 67 of staff working at the home had received fire safety training and 65 had undertaken fire safety drills. 80 staff had received Food hygiene training, 63 had received moving & handling training, and 92 had received training in respect of the Control of Substances Hazardous to Health (COSHH) and health and safety training. 80 of staff have undertaken training in respect of safeguarding vulnerable people from abuse, 61 have undertaken training in respect of nutrition, 18 of staff have received training for managing pressure area care. 100 of care staff have undertaken training in respect of the safe use of bedrails and 100 of senior care staff had undertaken training for the safe handling of medicines. Some staff working at the home have received training for dealing with challenging behaviour and dementia awareness. Six of the seven people who completed surveys said that staff working at the home have the right skills and experience to look after people properly. A Statutory Requirement Notice was issued following the last key inspection in respect of the registered providers failure to ensure that staff working at the home are provided with training appropriate for the work they are to perform. While this requirement has not been met there was evidence that the provider is working towards ensuring that all staff working at the home are trained for the work they are to perform and the needs of people living there. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been improvements in the way that the home is managed and run so that the interests of the people living there are considered and met. EVIDENCE: There was evidence that there have been residents meetings and that the homes manager has contacted residents and relatives so as to obtain their views about how the home is managed and the level of service provided. In addition to this the manager provided the Commission with the homes Annual Quality Assurance Assessment. This document clearly identified areas where a good level of service is provided, where improvements have been made and plans to improve the service in the future. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 23 There have been some marked improvements in the home since the last key inspection as identified throughout this report. Three of the seven people who completed ‘Have your say about’ surveys said that there have been improvements in the home in recent months and a number of people made positive comments about the manager and staff. Where monies are held on behalf of residents good records were maintained and checks carried out during the day of the inspection were satisfactory. Some but not all of the staff working at the home have received regular supervision. There was evidence that staff in the home undertake regular fire safety drills. Checks are carried out in respect of the systems and equipment for detecting and dealing with an outbreak of fire in the home. Certificates were available which evidenced that regular checks are carried out so as to ensure that the home is maintained safe and that the systems and equipment such as gas and electrical installations are in good working order. Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Timescale for action 30/08/07 2. OP12 16(2) (m) (n) 3. OP16 22 4. OP27 18 The arrangements for the safe handling, storage and administration of medicines by staff working in the home must be reviewed and urgent action taken so as to address the issues as identified within this report. More must be done so as to 30/09/07 provide a range of opportunities for activities and occupation for people living at the home who have dementia. Complaints must be received, 30/09/07 investigated and responded to in line with the homes policy and procedure. Staff must be employed in 30/09/07 sufficient numbers to meet the needs of the people who live at the home. (Previous timescale following the last four inspections, including the timescale of 28/02/06,30/07/06 & 30/12/06 & 30/05/07have not been met.) 5. OP29 19&sch.2 People must only be employed at 30/09/07 DS0000018098.V344360.R01.S.doc Version 5.2 Page 26 Mundy House Care Centre &4 the home once all of the checks as required by regulation have been carried out so as to ensure that they are fit and suitable to care for older people. (Previous timescales following the last four inspections including the most recent timescale of 30/03/06,30/08/06, 30/12/06 & 30/05/07 have not been met.) 6. OP30 18(1) (c) staff working at the home must receive the training and support they need so as to fulfil their roles according to their job descriptions and meeting the needs of the people who live at the home. (Previous timescales following the last inspections including the recent timescales of 30/03/06, 30/08/06, 10/01/07 & 22/6/07 have not been met.) 22/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP6 Good Practice Recommendations The provision of care for people admitted to the home for interim care should be reviewed so as to ensure the delivery of care and support is suited to their particular needs. Wherever it is possible the wishes of people living in the home in respect of how and where they would like to be cared for should their condition deteriorate or as they reach the end of their lives should be obtained and DS0000018098.V344360.R01.S.doc Version 5.2 Page 27 2. OP11 Mundy House Care Centre 5. OP36 recorded. All staff working at the home receive regular supervision Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mundy House Care Centre DS0000018098.V344360.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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